JEWELRY

DATE (MM/DD/YYYY)
JEWELRY SALES RECEIPT FOR INSURANCE PURPOSES
INSURANCE
STANDARDS
ORGANIZATION

CLIENT’S NAME AND ADDRESS

DESCRIPTION OF ARTICLE(S)
CLASS CODE # CODE DESCRIPTION EST REPLACEMENT VALUE

ITEM _______ OF _______ $

Mounting:

Karatage or % Color Metal Type Hallmarks Workmanship Gender Item Type Size MM Weight
(Mfg & Style #) (Ladies/Mens) (dwt. grm)
Stone(s): (each stone(s) grouping

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set S1e Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

# Stones Set Shape Type GIA Grade: (Cut/Make) Table % Crown Angle Girdle Thickness Pavilion % Culet Size Sym/Polish

MM x MM x MM x MM Color or (Tone/Saturation/Hue) Clarity Total Weight Approx? Avg Wgt

OPTIONAL DESCRIPTION

Color Photograph Attached

SIGNATURES
THIS IS NOT AN APPRAISAL
* The value set forth herein is the price at which the above described item was purchased and reflects the net price paid (excluding sales tax) at this store. All diamond and colored
stone grading herein is exclusively that of the Gemological Institute of America (GIA).

This detailed sales receipt is given to the customer named above and their insurer. The information herein shall inure to the benefit of the named customer's insurance company to
the same extent that they would the customer.

Jeweler Signature: Title: Date:

Print/Type Name:
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JISO 805 v.8/2005 (formerly ACORD 805) (incl material copyrighted by JCRS, Jewelry Underwriting & Claim Mitigation) © JISO 2005